Information
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Document No.:
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Observer:
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Supervisor:
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Date / Time:
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Client / Site:
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Company:
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Work area:
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Job / Task Being Performed:
PERSONNEL PROTECTION
SECTION I - PERSONAL PROTECTION
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I. HEAD PROTECTION
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1-HARD HAT Are hard hats in good condition, not altered in anyway? Are welders wearing a hard hat with their welding hoods?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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II. EYE PROTECTION
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1-SAFETY GLASSES (Z87+) WITH SIDE SHIELDS Are approved safety glasses worn at all times in designated work areas? Are glasses of the appropriate tint for the conditions?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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2-FACE SHIELD During activities, such as grinding, sanding, and blasting, are face shields being worn with safety glasses or sealed eye wear?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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III. HEARING PROTECTION
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1-EAR PLUGS Are ear plugs worn correctly in areas where high noise (85db or greater) is present?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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IV. HAND AND ARM
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1-PROPER GLOVES Are gloves being worn that are appropriate for the task? Are gloves in good condition (no holes, loose stitching, etc.)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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2-PROPER CLOTHING Is additional clothing being worn to protect the worker from hazards (long sleeves, apron, slicker,etc.)? Is clothing in good condition(no holes, tattered or frayed)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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3-EYES ON TASK (HANDS) Do workers keep their eyes on the work being performed & ignore distractions while doing tasks?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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V. FALL PROTECTION
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1-HAND/GUARD RAILS Are guard rails in place and secured to withstand 200lbs of side load? Are hand rails being used to ascend and descend stairs?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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2-SCAFFOLD INSPECTED Is inspection card complete & marked as inspected for the current shift by a competent person? Does scaffold appear as indicated on inspection card?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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3-ACCESS/ELEVATION Is the means of access/egress provided to the workers to the elevated area safe?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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4-WALKING SURFACE Are all main walkways kept level and clear of any cluttered, materials, chemicals, movable equipment and tools, which could cause a tripping or slipping hazard?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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5-PROPER ANCHOR Are workers anchored above their d-ring so as to not contact the level below? Are anchor points adequate to withstand a fall (i.e. 3in diameter pipe or larger [full supported, i. e. welded or bolted up, not lashed or in the rigging], structural steel or manufacturers' approved anchor points)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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6-100% FALL PROTECTED Are workers tied off at all times when at 6 feet or greater from the level below?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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7-PORTABLE LADDER USE Are ladders inspected before use (color code)? Does ladder have a means of preventing tip over (tied at the top or held by an additional worker)? Are workers using fall protection where required?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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8-EYES ON PATH Are workers looking in the direction of travel (i. e. looking back before stepping back)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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9-FALL PREVENTION PLANNING Is working at elevation properly planned, permits obtained, rescued planned, etc.?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
SECTION II - BODY USE/AWARENESS
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III. LIFTING
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1-TECHNIQUE Are workers lifting with their legs, not bending at the waist? Are arms kept close to body while lifting objects?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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2-MECHANICS Are workers trying to lift more than can safely? Are workers twisting at the hips
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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IV. LINE OF FIRE
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1-SELF Are workers making sure to not position themselves where they could get hurt (standing under loads, close to flying debris, where chemicals could escape, etc.)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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2-OTHERS Are workers aware of those around them, watching out for their fellow workers so as to not put them in the line of fire (using screens, barricade tape,etc.)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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2-OTHERS Are workers aware of those around them, watching out for their fellow workers so as to not put them in the line of fire (using screens, barricade tape,etc.)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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IV. BODY TRAPS
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1-HOT SURFACES Are workers aware of hot surfaces around them (welds, un-insulated steam or condensate lines, etc.)?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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2-PINCH POINTS Are workers avoiding areas where their hands or body could get caught between any two objects?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
SECTION III - CONFINED SPACE ENTRY (CSE)/EXCAVATION
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I. PERMITS
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1-PERMITS Are permits complete & posted at location?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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II. CONFINED SPACE ENTRY PPE
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1-PERMITS Are workers using additional PPE specific to hazards identified?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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III. SLOPING/SHORING
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1-SLOPING/SHORING Has the soil been examined to determine the proper slope and/or shoring to use? Is the proper sloping and/or shoring being used?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
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IV. PROPER ACCESS/EGRESS
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1-PROPER ACCESS/EGRESS Has a safe access/egress been established? Are workers trained in proper rescue?
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If act or condition is at risk, take a picture and make notes, including any corrective actions taken.
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Unsafe act or condition:
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Corrective action(s):
SECTION IV - MISCELLANEOUS
SECTION V - PLANT/SITE SPECIFICS
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Sketch the item.
BODY USE/AWARENESS
